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Arterial Assessment

  1. Clinical Assessment
    1. Claudication
      1. Calf or thigh pain precipitated by exercise. Usually occurs after predictable distance. Relieved by rest
      2. Progression of symptoms is important - worsening or improvement
      3. Need to differentiate form spinal stenosis: Also cause exercise induced leg pain; Usually associated with neurological symptoms and relieved by spinal flexion
      4. Peripheral pulses can be present in patients with intermittent claudication  
    2. Ankle-Brachial Index
      1. An ABI <0.9 correlates with increased risk of myocardial infarction and indicates significant, although perhaps asymptomatic, underlying peripheral vascular disease.
      2. Blood pressure (BP) is measured in both upper extremities along with ankle using a pencil Doppler probe over posterior tibial and dorsalis pedis  artery.
      3. The ratio of the systolic pressure in each vessel divided by the highest arm systolic pressure can be used to express the ABI in both the posterior tibial and dorsalis pedis arteries. Normal is more than 1.
      4. Patients with claudication typically have an ABI in the 0.5 to 0.7 range, and those with rest pain are in the 0.3 to 0.5 range. Those with gangrene have an ABI of <0.3. 
    3. Critical limb ischaemia
      1. Characterised by rest pain
      2. Occurs when foot is elevated (e.g. in bed)
      3. Improved with foot dependent
      4. May be associated with ulceration or gangrene
      5. Foot pulses are invariably absent. 
  2. Non-invasive testing of arterial patency Q
    1. Hand-held Doppler
      1. Reflection of an ultrasound wave off a stationary object does not change its frequency. Reflection off a moving object results in a change of frequency
      2. The change in frequency is proportional to velocity or blood flow
      3. Hand held 8 MHz doppler probe is used to assess arterial system
      4. Can be used to measure arterial pressures (at rest and after exercise).
      5. In normal individual lower limb pressures are greater than upper limb
      6. Ankle-brachial pressure index (ratio of best foot systolic to brachial systolic Pr)         
    2. Toe pressures
      1. Provides accurate assessment of distal circulation
      2. Not influenced by calcification in pedal vessels
      3. Normal toe pressures are 90-100 mmHg
      4. Toe pressure less than 30 mmHg suggests critical limb ischaemia  
    3. Duplex ultrasound
      1. Combined pulsed doppler and real time B mode ultrasound
      2. Allows imaging of vessels and any stenotic lesion.
      3. Flow and pressure wave form can be also be assessed
      4. Duplex ultrasound has sensitivity of 80% and specificity of 90%.  
    4. Pulse generated run off
      1. Proximal occlusion often causes poor filling of crural vessels on arteriography
      2. Rapid cycling of a proximal cuff generates arterial pulse wave
      3. P GR allows functional testing of distal arterial patency
        Magnetic resonance angiography: No contrast required.
  3. Invasive vascular assessmen
    1. Angiography
      1. Usually performed using digital subtraction techniques
      2. Femoral artery is commonest site of venous access.
      3. Potential complications include
        1. Contrast-related: Anaphylactic reaction/ Toxic reactions. Deterioration in renal function
        2. Technique-related: Haematoma/ Arterial spasm/ Sub-intimal dissection/ False aneurysm/ Arteriovenous fistula/ Embolisation/ Infection  
    2. CT angiography
      1. Required intravenous contrast and ionising radiation
      2. Spiral CT and reconstruction can provide detailed images
      3. Particularly useful for the assessment of aneurysmal disease  
    3. Acute limb ischaemia
      1. ​​Effects of sudden arterial occlusion depends on state of collateral supply  
  4. Aetiology of acute limb ischaemia
    1. Embolism
      1. Left atrium in patients in atrial fibrillation
      2. Mural thrombus after myocardial infarct
      3. Prosthetic and diseases heart valves
      4. Aneurysm or atheromatous stenosis
      5. Tumour, foreign body, paradoxical
  5. Thrombosis
    1. Trauma
    2. Dissecting aneurysm
    3. Raynaud's Syndrome
    4. Clinical features of limb ischaemia
      1. Clinical diagnosis depends on the 6 'P' s
        Pain/ Paraesthesia/ Pallor/ Pulselessness/ Paralysis/ Perishing with cold
      2. Objective sensory loss requires urgent treatment Q
      3. Need to differentiate embolism from thrombosis
      4. Important clinical features include
        1. Rapidity of onset of symptoms
        2. Features of pre-existing chronic arterial disease
        3. Potential source of embolus
        4. State of pedal pulses in contralateral leg  
  6. Management of acute ischaemia
    1. Heparinise & analgesia. Treat associated cardiac disease
    2. Treatment options are:
      1. Embolic disease - embolectomy or intra-arterial thrombolysis
      2. Thrombotic disease - intra-arterial thrombolysis / angioplasty or bypass surgery  
  7. Emergency embolectomy: Q Can be performed under either general or local anaesthesia
    1. Transverse artereotomy performed over common femoral artery
    2. Fogarty balloon embolectomy catheters used to retrieve thrombus
    3. If embolectomy fails - on-table angiogram and consider
      1. ​​Bypass graft or intraoperative thrombolysis  
  8. Intra-arterial thrombolysis:
    1. Arteriogram and catheter advanced into thrombus. Streptokinase 5000u/hr + heparin 250u/hr
    2. Alternative thrombolytic agents are urokinase/ tissue plasminogen activator (tPA).
    3. Repeat arteriogram at 6 -12 hours
    4. Advance catheter and continue thrombolysis for 48 hours or until clot lysis.
    5. Angioplasty of chronic arterial stenosis may be necessary

Contraindications to Thrombolytic Therapy

Absolute contraindications

Established cerebrovascular events (including transient ischemic attack) within last 2 mo

Active bleeding diathesis

Recent (<10 d) GI bleeding

Neurosurgery (intracranial or spinal) within last 3 mo

Intracranial trauma within last 3 mo

Intracranial malignancy or metastasis

Relative major contraindications

Cardiopulmonary resuscitation within last 10 d

Major nonvascular surgery or trauma within last 10 d

Uncontrolled hypertension (>180 mmHg systolic or >110 mmHg diastolic)

Puncture of noncompressible vessel

Intracranial tumor

Recent eye surgery

Minor contraindications

Hepatic failure, particularly with coagulopathy

Bacterial endocarditis


Diabetic hemorrhagic retinopathy

Ref: Schwartz's Principles of Surgery 9th Edition Ch 13


American College of Chest Physicians Recommendations Regarding Duration of Long-Term Antithrombotic Therapy for Deep Vein Thrombosis (DVT)

Clinical Subgroup

Antithrombotic Treatment Duration

First episode DVT/transient risk

VKA for 3 mo

First episode DVT/unprovoked

VKA for at least 3 mo

Consider for long-term therapy if:

Proximal DVT

Minimal bleeding risk

Stable coagulation monitoring

Distal DVT/unprovoked

VKA for 3 mo

Second episode DVT/unprovoked

VKA long-term therapy

DVT and cancer

LMWH 3–6 mo


Then VKA or LMWH indefinitely until cancer resolves

LMWH = low molecular weight heparin; VKA = vitamin K antagonist.


Ref: Schwartz's Principles of Surgery 9th Edition Ch 24

  • Buerger Disease (Thromboangiitis Obliterans)
    1. Thromboangiitis obliterans is a nonatherosclerotic, segmental, inflammatory, vasoocclusive disease that affects the small and medium-sized arteries and veins of the upper and lower extremities. Q
    2. It is strongly associated with heavy tobacco use.
      Male-to-female ratio = 3:1and majority of patients are aged 20-45 years.  
  1. History: Because a firm diagnosis of thromboangiitis obliterans is difficult to establish, a number of different diagnostic criteria have been proposed:
    1. Age younger than 45 years
    2. Current (or recent) history of tobacco use
    3. Presence of distal-extremity ischemia (indicated by claudication, pain at rest, ischemic ulcers, or gangrene) documented by noninvasive vascular testing
    4. Exclusion of autoimmune diseases, hypercoagulable states, and diabetes mellitus by laboratory tests
    5. Exclusion of a proximal source of emboli by echocardiography and arteriography
    6. Consistent arteriographic findings in the involved and noninvolved limbsQ
Patients also may present with claudication of the feet, legs, hands, or arms and often describe Raynaud phenomenon of sensitivity of the hands and fingers to cold. 
  1. Physical:
    1. The diseased hands and feet are usually cool and mildly edematous.
    2. Superficial thrombophlebitis is often migratory (in 50%). Paresthesias (numbness, tingling, burning, hypoesthesia) of the feet and hands.
    3. Impaired distal pulses in the presence of normal proximal pulses. 

Imaging Studies:




This lower extremity arteriogram of the peroneal and tibial arteries of a patient with Buerger disease demonstrates the classic findings of multiple small and medium-sized arterial occlusions with formation of compensatory "corkscrew collaterals." B & C

  1. Other Tests:
    An abnormal Allen test indicating distal arterial disease and establishing involvement of the upper extremities in addition to the lower extremities helps to differentiate thromboangiitis obliterans from atherosclerotic disease.  
  2. Treatment: Absolute discontinuation of tobacco use.
    Treatment with intravenous iloprost (a prostaglandin analogue), has been shown to improve symptoms, accelerating resolution of distal extremity trophic changes. Q 
  • Surgical Care:
    1. Given the diffuse segmental nature and that the disease affects primarily small and medium-sized arteries; surgical revascularization is usually not feasible.
    2. Autologous vein bypass of coexistent large-vessel atherosclerotic stenoses should be considered in patients with severe ischemia who have an acceptable distal target vessel.
    3. Other proposed surgical treatments for thromboangiitis obliterans are:
      1. Omental transfer (Omento pexy)
      2. Sympathectomy
      3. Spinal cord stimulator implantation
    4. Distal limb amputation for nonhealing ulcers, gangrene, or intractable pain may be required.

Neuropathic Ulcer

Ischemic Ulcer



Normal pulses

Absent pulses

Regular margins, typically punched-out appearance

Often located on plantar surface of foot

Irregular margin

Commonly located on toes, glabrous margins

Presence of calluses

Calluses absent or infrequent

Loss of sensation, reflexes, and vibration

Variable sensory findings

Increased in blood flow (atrioventricular shunting)

Decreased in bloo flow

Dilated veins

Collapsed veins

Dry, warm foot

Cold foot

Bony deformities

No bony deformities

Red or hyperemic in appearance

Pale and cyanotic in appearance


Differential Diagnosis of Intermittent Claudication



Location of Pain or Discomfort

Characteristic Discomfort

Onset Relative to Exercise

Effect of Rest

Effect of Body Position

Other Characteristics

Intermittent claudication (calf)

Calf muscles

Cramping pain

After same degree of exercise

Quickly relieved



Chronic compartment syndrome

Calf muscles

Tight, bursting pain

After much exercise (e.g., jogging)

Subsides very slowly

Relief speeded by elevation

Typically heavy-muscled athletes

Venous claudication

Entire leg, but usually worse in thigh and groin

Tight, bursting pain

After walking

Subsides slowly

Relief speeded by elevation

History of iliofemoral DVT, signs of venous congestion, edema

Nerve root compression (e.g., herniated disk)

Radiates down leg, usually posteriorly

Sharp lancinating pain

Soon, if not immediately after onset

Not quickly relieved (often at rest)

Relief may be aided by adjusting back position

History of back problems

Symptomatic Baker's cyst

Behind knee, down calf

Swelling, soreness, tenderness

With exercise

Present at rest


Not intermittent

Intermittent claudication (hip, thigh, buttock)

Hip, thigh, buttocks

Aching discomfort, weakness

After same degree of exercise

Quickly relieved



Hip arthritis

Hip, thigh, buttocks

Aching discomfort

After variable degree of exercise

Not quickly relieved ( may
be at rest)

More comfortable sitting, weight taken off legs

Variable, may relate to activity level, weather changes

Spinal cord compression

Hip, thigh, buttocks (follows dermatome)

Weakness more than pain

After walking or standing for same length of time

Relieved by stopping only if position changed

Relief by lumbar spine flexion (sitting or stooping forward) pressure

Frequent history of back problems, provoked by increased intra-abdominal pressure

Intermittent claudication (foot)

Foot, arch

Severe deep pain and numbness

After same degree of exercise

Quickly relieved



Arthritic, inflammatory process

Foot, arch

Aching pain

After variable degree of exercise

Not quickly relieved (may be at rest)

May be relieved by not bearing weight

Variable, may relate to activity level

Ref: Schwartz's Principles of Surgery 9th Edition Ch 13

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